Recommendations on Immunization

IAP is in a dilemma!

Time and again, recommendations of IAPCOI have come under severe flak and criticism from one quarter or the other. For pretext ranging from changing recommendations under pressure from one vaccine firm to accepting commercial inducement offered by the other! People have always taken IAP’s recommendations with certain amount of skepticism, some times with some valid reasons behind, sometimes quite unjustifiably! Though, majority of them are still following the schedule put forward by IAP, an element of cynicism remains because everybody engaged in vaccination practice considers him/herself as an expert in the field and anything suggested contrary to their practicing norms breeds a sense of resentment and disapproval. In almost every session on immunization, the one most consistent query is, “whether IAP recommendations on immunization are being influenced by vaccine manufacturers?” Though, in a time of massive individual sponsorship by the pharmaceuticals, majority of us probably lost moral right to ask such a question, but nevertheless, the onus of proving immune to manipulations made and inducements offered by the industry is entirely rest on IAPCOI!
The reasons behind genesis of this skepticism and suspicion may vary with the instance involved, but over-reliance on vaccine manufacturers to get its recommendations, guidebooks and even vaccination cards published by them is the most compelling reason behind this mistrust on IAPCOI. IAP must learn to bear the expenditure on publishing its important policy statements including recommendations on immunization to dispel any doubts raised on its integrity.There is still lot of confusion prevailing in the immunization circle and probably, IAP is in a

dilemma. It is not very sure which immunization schedule should it endorse: the one which suites an individual the most, or the one that finds acceptance for mass use. Let’s look at the system followed in US. The AAP makes recommendations on immunization every year based on local epidemiology and prevailing trends, catering best to the needs of an individual protection, and then it present these recommendations to CDC, which most of the time incorporate them in toto into their national immunization schedule. Thus, in US the recommendations and immunization schedules of AAP and NIP are almost identical and they work in total unison. However, American society is far more well-off and more homogenous socio-economically than India, which is characterized by marked disparity socio-demographically even in the same geopolitical regions and weak economically, hence, the need to have different recommendations for different segments of the society. This is the reason why the immunization schedule suggested by IAP and the one adopted by GOI differ markedly and will continue to differ in future too. However, what is feasible for mass use programmatically may not always be most sound scientifically and might be undesirable at times. Therefore, IAP should recommend two different schedules- one that is best for individual protection fulfilling all the criteria of an ideal vaccination schedule, based on prevailing epidemiology and free from logistic considerations and another for adoption at mass level as a national immunization schedule taking programmatical feasibility and logistical considerations in to account.
There is need to redesign both the existing schedules. For example, the proposed 6,10,14 week Hep-B schedule adopted by GOI for universal immunization is though programmatically more acceptable but scientifically suffers being an irrational one as it does not offer protection against perinatal transmission, which constitutes major mode of Hep-B transmission in India. Provision of single dose of measles is another aberration that needs to be supplemented with an additional dose preferably in form of MMR at 12-18 mo of age. Provision of last dose of Hep-B series before 6 mo of age, booster of MMR, and proper timing of Hep-A vaccination are few controversial spots in IAP’s schedule.
Now, IAP through its representation to NTAGI, gets an opportunity to present its recommendations to national health policy makers, so that a more appropriate schedule can be devised that not only proves more feasible for mass implementation but scores on ‘scientific rationality’ front too. Further, it also can stress upon the need to prioritize diseases, depending upon their epidemiological burden that need to be controlled through an effective vaccination program. The vaccine against some of these may not be available in Indian market but are available elsewhere (such as pneumococcal) or are in the process of development (such as rota virus and other diarrheal diseases). Even possibilities of developing few of them indigenously can be explored.
-Dr. Vipin M. Vashishtha